Failure to Properly Manage and Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure proper management and reconciliation of controlled substances for multiple residents and medication carts. Surveyors observed that discontinued and expired medications were not consistently removed from medication carts on several occasions. Additionally, there were repeated failures to reconcile the administration and count of controlled substances, with numerous instances where counts were not completed or signed for as required. These lapses were identified through observation, interviews, and record reviews involving several residents with complex medical histories, including dementia, pain management needs, and anxiety disorders. Specific findings included the presence of expired or discontinued medications in medication carts, such as Lorazepam and Tramadol, which were not removed after the prescribed period or after discontinuation. In some cases, controlled substances were not administered as documented, and discrepancies were noted between medication administration records and controlled substance logs. Staff interviews revealed inconsistent practices regarding the counting and documentation of controlled substances, with some staff admitting to not counting at the beginning of shifts or failing to sign count records. There were also instances where medications were wasted without the required signatures or without two licensed staff present, contrary to facility policy. Review of facility policies confirmed that controlled substances should be counted at every shift change, with both incoming and outgoing staff signing the records, and that expired or discontinued medications should be promptly removed from carts. However, interviews with nursing and administrative staff indicated a lack of consistent adherence to these policies, with some staff unaware of the requirements or admitting to lapses in practice. The facility's documentation showed numerous missing signatures on controlled drug count records across multiple medication carts and shifts, further evidencing the breakdown in controlled substance management.